Opening the door for communication in a nonjudgmental manner is essential for pharmacists to counsel patients on cannabis use.
In recent years, medical cannabis use has been rapidly gaining traction, so it is critical for pharmacists to understand the clinical and pharmacologic uses and different products to better assist their patients interested in using them.
“The regulations are changing and it is really important, for us, as pharmacists, to know how its regulated in our states,” Kam Capoccia, PharmD, BCPS, CDCES, clinical professor of community care at the Western New England University College of Pharmacy and Health Sciences, said during a presentation at the American Pharmacists Association Annual Meeting 2022.
According to Capoccia, all marijuana is illegal federally when derived from cannabis sativa, cannabis indica, and cannabis ruderalis.
Cannabis sativa and cannabis indica are the most frequently used plants. Marijuana derived from cannabis sativa is primarily tetrahydrocannabinol (THC), with low cannabidiol (CBD), whereas marijuana derived from cannabis indica is higher CBD but has variable amounts of THC.
Hemp derived from cannabis sativa is legal federally, which is primarily CBD, with THC less than or equal to 0.3%, and is typically used in medicinal products.
“Within the plant itself, pretty much every part of the plant is used for something,” Capoccia said during the presentation. “So, whether it be the dry flowers, the stems, the leaves, the seeds, the industry really has a purpose and a use for all parts of the plant.”
Capoccia also outlined the differences between extracts and concentrates. Extracts, Capoccia said, use solvents to take components out of the plant, whereas concentrates use a mechanical mechanism to change into the final product.
Different products can be made from different parts of the cannabis plant. For example, shatter is a thin glass-like sheet; rosin is a concentrate with an oil-like consistency; resin is the compound remaining after smoking; oils can be smoked, vaporized, or used in edibles; and hash is a very concentrated product. All of these are different forms that can be used.
Based off these forms, patients can use the products through inhalation, topicals, oils, and edibles. Smoking is one of the most common uses, with the onset of time peaks within 20 to 30 minutes after use.
Topicals, however, do not enter the blood stream, so it requires frequent application to get the full effect of the CBD, whereas oils are used as sprays and extracts that offer isolate, broad spectrum, and full spectrum effects, varying in CBD and THC content.
Edibles have a varied onset time, which make them more inconsistent in terms of dosing.
“The onset can be a half-hour, it could be 2 hours, it can be 2 and a half hours,” she said during her presentation. “If our patients do not know or recognize that it takes a couple of hours for this to kick in, they take 1, ‘it’s not really working,’ an hour later ‘I’m going to take another one.’”
She said that this is one of the most important counseling points that pharmacists can offer to patients.
She suggests that pharmacists should recommend to patients to journal about their use of medical cannabis when prescribed. The dosage should start low and slowly increase, and the patient should log their adverse effects and how helpful it has been for them to help the pharmacist make recommendations.
Capoccia noted a lack of evidence in trials regarding cannabis use, however, there are some data and compilation of evidence in this area. During a question-and-answer session, it was noted that the evidence about medicinal cannabis was lacking because of its criminalization. Now, Capoccia said, funding for cannabis research could be lacking due to the wide-spread use of the drug.
Nevertheless, there is conclusive, or at least, substantial evidence about cannabis use for chronic pain in adults; antiemetic oral cannabinoids for chemotherapy-induced nausea and vomiting, which is an FDA-approved indication; and oral cannabinoids for patient-reported multiple sclerosis spasticity, Capoccia said.
Interestingly, there is evidence that supports cannabis products being used to treat neuropathic pain. The evidence suggests that with use of cannabis products, opioid use decreases, therefore research efforts may benefit from analyzing a link between opioid use and cannabis use.
Capoccia concluded that the pharmacist’s role is to educate patients on cannabis use. She said that opening the door for communication and considering patients’ use history in a nonjudgmental manner is essential for effective interaction.